Registered Nurse-Clinical Vendor Oversight Specialist (CMS/Medicare Auditing experience in a health plan)
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
For Medicare and Commercial business, is responsible for conducting annual delegation clinical audits and reviews to ensure standardization and consistency with nurse reviewer clinical decisions.
Provide professional oversight on vendor delegation and ensure accuracy and compliant policies and procedures with internal and regulatory compliance standards.
Provide clinical and operational analysis and project coordination support/leadership.
- Perform quality audits to ensure standardization and consistency with clinical decisions.
- Assist with the development and evaluation of performance goals and objectives and quality management activities.
- Perform operational and compliance analytics, develop required reports, provide second level review of data and suggest improvements.
- Meet quality, quantity and timeliness standards to achieve department performance goals as defined within the department and CMS guidelines.
- Monitor delegated entities for quality and contract requirements and maintain reporting for evaluation and departmental reporting.
- Assist with the development of policies, procedures, service level agreements for contracted entities, delegation and/or oversight review, and ongoing monitoring of adherence to the aforementioned.
- Implement, manage and report on quality vendor and accreditation projects and programs.
- Demonstrate and maintain current working knowledge of the required systems, procedures, forms and manuals.
- Consult and coordinate with various internal departments, external plans, providers, vendors, businesses and government agencies to obtain information to meet departmental and corporate projects and goals.
- Conduct analysis of business and user needs in order to develop requirements for the creation or revision of reports, systems or applications for specified business units.
- Support oversight of program data collection and create reports to evaluate current programs.
- Maintain current knowledge and adherence to CMS guidelines and policies, department policies, local medical policy guidelines, Federal guideline/policy updates, and delegation criteria as it relates to the operations of the departments. This may involve coordinating with Medical Directors, the Compliance department BCBSAZ departments.
- Create and Maintain:
- Job aids
- Documentation of processes to maintain CMS and/or URAC accreditation
- When indicated to assist with team/project functions:
- Collaborate with team to distribute workload/work tasks;
- Monitor and report team tasks;
- Communicate team issues and opportunities for improvement to supervisor/manager;
- Support/mentor team members
- Actively participate in inter-departmental meetings, special projects, or quality projects as assigned.
- Provide trainings to new hires, existing associates and delegated entities.
- Participate in continuing education and current development in the field of medicine and managed care.
Perform all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards.
- The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
- Perform all other duties as assigned.
- Required Work Experience
- 2 years of experience with Medicare compliance, CMS requirements, auditing business and operational outcomes
- 2 years of experience in a clinical field of practice or other health care related field
- 2 years of experience in health insurance
- Required Education
- Associate's Degree general field of study, or post high school nursing diploma.
- Required Licenses
- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse
- Preferred Work Experience
- 4 years of experience with Medicare compliance, CMS requirements, auditing business and operational outcomes
- 3 years of experience in health insurance
- Preferred Education
- Bachelor's Degree in Nursing
- Required Job Skills
- Strong written and verbal communications. Excellent organizational skills and strong attention to detail
- Possess proficient computer and technological skills especially Word, Excel and PowerPoint
- Ability to gather, analyze data and prepare informative and accurate reports.
- Required Professional Competencies
- Maintains current knowledge of State, Federal, BCBSAZ, and other applicable regulatory/accrediting agency requirements
- Knowledge of managed care, utilization management, and quality management
- Ability to proficiently assess and utilize business enterprise solutions and workflows to achieve outcomes adherent to clinical best practice, CMS and Medicaid regulations.
- Ability to develop, organize, motivate, coordinate and collaborate effectively with stakeholders from multiple business areas across the organization
- Capable of investigative and analytical research to make decisions and reommendations based on available information
- Independent and sound judgment with good problem solving skills
- Ability to maintain confidentiality and privacy
- Demonstrated organizational skills with the ability to prioritize tasks and work with multiple priorities
- Establish and maintain working relationships in a collaborative team environment
- Required Leadership Experience and Competencies
- Mindset geared toward the creation, execution and continuous improvement of clinical department and programs. Intellectual curiosity and ability to view old problems/issues with a fresh perspective.
- Ability to perform job role duties independently.
- Ability to coordinate/lead small projects
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.